Medicare Coverage of Ostomy Supplies

One of the most common questions about home medical supplies is “what’s covered?” Specifically, Medicare coverage of ostomy supplies. Because managing an ostomy at home involves ordering an assortment of products and accessories, knowing what to expect is helpful.

Qualifying For Ostomy Supplies

Original Medicare has two parts. Part A: Hospital Insurance that covers hospital, home health and skilled nursing stays and Part B: Medical Insurance that covers a variety of outpatient services including medical supplies, including ostomy supplies

Medicare eligibility and payment guidelines for Part B benefit:

Monthly Premium – automatically deducted from Social Security check and amount changes every January 1st

Annual Deductible – Medicare beneficiary is responsible for an annual deductible for Part B supplies or services beginning every January 1st

Allowable Fee – Value determined by Medicare for the supply or service

Medicare responsibility – 80% of allowable fee

Beneficiary responsibility – 20% of allowable fee

To qualify for ostomy supplies for care at home, you must have Medicare Part B coverage and your doctor’s documentation of your need for the supplies in your medical records. The doctor must also write you a prescription or order for the supplies clearly stating which supplies you will need. Your doctor will know what’s necessary to qualify for the type of supplies prescribed for you. You are allowed up to a three-month supply of ostomy products at one time. Ostomy supplies are covered for people with a Colostomy, Ileostomy or Urostomy.

How Much Ostomy Supplies Will Medicare Cover?

Medicare decides the amount of supplies you may order each time. The quantity of supplies needed by each person is decided by the type of ostomy, its location, its construction and the condition of the skin around the ostomy. Medicare may approve increased supplies if those supplies are deemed medically necessary by your doctor.

If you receive your Medicare through a Medicare Advantage Plan (such as an HMO or PPO), there may be additional benefits and other criteria for ordering your supplies. Make a point of checking with your health plan’s customer service department before ordering your supplies.

13 Comments

Cindy Weaver

Posted September 24, 2013 at 4:01 pm PST

I don’t understand how Medicare can tell a person how many ostomy supplies he/she can have each month !! There is NO way of telling how many you will need each month because of leaks. Even if the skin around the stoma is ok, there can always be leaks! I have experienced this many times !

So what is a person supposed to do if they run out? Paying out of pocket would be VERY expensive!

Hi Cindy,
We understand your frustration. Unfortunately, the amount of supplies you can order is limited by Medicare. Since Medicare may approve increased supplies if your doctor deems them medically necessary, we recommend you speak with your primary care physician. You might also consult with an ostomy support group for ideas or suggestions.

marliyn balsse

Posted March 31, 2015 at 11:18 pm PST

No, you do not understand our frustration as a colostomy patient. I have used 10 bags within 2 days if I have the flu or a virus or leaks. Medicare is very unfair with colostomy patients. diabetic patients receive free shoes and other free supplies. I do not know who in medicare made the rules for colostomy patients but they are way off base.

Brett

Posted May 5, 2015 at 2:20 pm PST

What about stoma paste?

Aimee Sharp

Posted May 5, 2015 at 6:44 pm PST

Hi Brett. Thank you for your question. It looks like 4 ounces of ostomy paste per month is eligible for reimbursement through Medicare. You can find more information about Medicare reimbursement here, if need be. Thanks for commenting!

Tom

Posted September 30, 2015 at 12:40 pm PST

Will Shield accept a prescription from a doctor calling for what the doctor determines medically necessary even though it is more that medicare normally allows?

Aimee Sharp

Posted October 1, 2015 at 3:03 pm PST

Hi Tom. Thank you for commenting. To answer your question: In general, Shield HealthCare follows Medicare’s guidelines. If you have a specific question, we’d ask that you give us a call and we would be able to discuss. 800.765.8775. Thank you! -Aimee, Shield HealthCare

Mary Jane

Posted March 8, 2016 at 6:48 am PST

do you all accept Medicaid

Aimee Sharp

Posted March 18, 2016 at 4:58 pm PST

Hi Mary Jane. Thank you for your question. We accept Medicaid in IL, WA, CO and TX, and Medi-Cal in California. Please let us know if you have any other questions. Thank you. -Aimee, Shield HealthCare

Nancy

Posted March 25, 2016 at 4:50 am PST

What kind of note do I need from my Dr? Does
he have to list what supplies I need- like numbers? How do I get the note to you?
Thanks

Hi Nancy, thank you for your question! In order to receive ostomy products, a prescription from your doctor is required. Depending on your state and your insurance, there may be other variables involved. We would be happy to give you a more detailed answer – at your convenience, please contact us at 800.765.8775 and we will be glad to assist you. -Brooke, Shield HealthCare

Mark

Posted May 11, 2016 at 11:01 am PST

I have a stoma in the neck area. Medicare and Medicaid will only cover orders/ claims for diagnosis and codes for Colostomy, lleostomy, and Urostomy. Is there something I’m missing relating to coverage for unique stoma ostomy pouch supplies? I can’t afford the out of pocket cost. Has anyone had a appeal court hearing with any success?

Aimee Sharp

Posted August 15, 2016 at 2:33 pm PST

Hi Mark. Thanks for commenting. I’m sorry, but we don’t have any information about that type of ostomy pouch and its coverage. Hopefully a fellow reader will see your comment and answer. We wish you the best of luck in the meantime! -Aimee, Shield HealthCare

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Shield HealthCare, established in 1957 is an industry leader in home-delivered Incontinence, Urological, Ostomy, Enteral Nutrition, and Wound Supplies.